MOMETASONE

mometasone furoate 0.1% lotion, 30 mL

MOMETASONE (10805Q)

mometasone furoate 0.1% lotion, 30 mL
10805Q
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

Restriction  6218

Indication: Corticosteroid-responsive dermatoses

Restriction  6263

Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 4 # of repeats: 5 DPMQ: $34.72 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Novasone
Zatamil
Elocon
*Additional charge for this brand is $22.00
 DPMQ: $56.72 Max safety net: $25.00 General Patient Charge: $47.00